The Importance of Training Dais and Traditional Birth Attendants in Safe Practices

In many rural communities across the globe, especially in developing countries, traditional birth attendants (TBAs)-known as Dais in South Asia-serve as the first point of contact for pregnant women. These community-based providers assist with deliveries and offer maternal care where healthcare facilities may be difficult to access. Training these attendants in safe practices is critical for improving birth outcomes and reducing preventable deaths among mothers and newborns.

Who are traditional birth attendants? 🔗

A traditional birth attendant is a pregnancy and childbirth care provider who assists women during delivery based primarily on experience and knowledge acquired informally through the traditions and practices of their community. They typically work in rural, remote, and medically underserved areas where formal healthcare services are limited or inaccessible.

TBAs are often older women who are respected in their communities for their knowledge and experience. In India, they are commonly called Dais-typically older or widowed women who draw upon years of experience and generations of traditional knowledge for their delivery practice. They learn their skills through apprenticeships with more experienced TBAs rather than through formal education.

In many developing countries, 60 to 80 percent of deliveries are assisted by traditional birth attendants. Despite government efforts to promote institutional deliveries, many women in remote areas continue to prefer home births conducted by a dai due to accessibility of care, community trust, and sometimes negative perceptions of government health facilities.

Why training Dais matters 🔗

The strength of TBAs lies in their deep connection to the cultural and social fabric of their communities. However, certain traditional practices can pose risks to mothers and babies. With appropriate training and supervision, these dangers can be minimized while their potential to improve maternal and child health outcomes is maximized.

Addressing the healthcare gap 🔗

Many women in rural areas lack access to skilled birth attendants or healthcare facilities. TBAs serve as crucial links between families and the formal healthcare system, especially in areas where geographic barriers, financial constraints, or cultural factors prevent women from accessing institutional care.

Training programs help TBAs recognize danger signs during pregnancy and delivery, ensuring timely referrals to healthcare facilities when complications arise. This referral function is particularly important because most maternal deaths from direct causes such as hemorrhage, obstructed labor, infections, and eclampsia could be prevented if women received timely care at critical moments.

Reducing maternal and infant mortality 🔗

Training traditional birth attendants has shown promising results in reducing deaths. A study in Pakistan demonstrated that community-based interventions using lady health workers and trained Dais led to a reduction in neonatal mortality from 57.3 to 41.3 per 1000 live births, along with an increase in facility deliveries from 18 to 30 percent.

Research from India shows that community mobilization programs in resource-poor states like Jharkhand and Orissa achieved a 45 percent reduction in neonatal mortality rates through women’s groups that promoted safe delivery practices and care-seeking behavior. Similarly, an effective program in Pakistan reported a 28 percent reduction in neonatal mortality through training TBAs in home-based neonatal care.

Key components of Dai training programs 🔗

Effective training programs for traditional birth attendants focus on several essential areas to ensure safe practices during pregnancy and childbirth.

Recognition of danger signs 🔗

TBAs are trained to identify warning signs that indicate complications requiring immediate medical attention. These include prolonged labor, excessive bleeding, fever, convulsions, and abnormal fetal positions. Early recognition of these signs enables prompt referral to healthcare facilities, potentially saving lives.

Hygienic delivery practices 🔗

Training emphasizes clean delivery techniques to prevent infections. TBAs learn proper handwashing, use of sterile equipment, and safe cord care. Programs often provide safe delivery kits containing sterilized materials necessary for aseptic practice, including clean blades for cutting the umbilical cord and gloves.

The Jan Swasthya Sahyog dai training program in India reported that the occurrence of unsafe practices such as the overuse of oxytocin has greatly decreased in programme villages after training. Umbilical cord infections have also declined as more dais have taken responsibility for cutting the cord using sterile techniques.

Emergency management skills 🔗

Training includes practical skills for managing emergencies when rapid transport to a hospital is not possible. For instance, trained TBAs learn techniques to manage postpartum hemorrhage through uterine compression-a life-saving intervention when immediate medical care is unavailable.

Nutrition and postnatal care 🔗

TBAs are educated about proper nutrition for mothers during pregnancy and after delivery, the importance of early and exclusive breastfeeding, and essential newborn care practices. This includes delayed bathing of newborns, proper cord care, and keeping the baby warm.

The importance of supervised experience 🔗

Effective TBA training goes beyond classroom instruction. Practical demonstrations and supervised experience are crucial components that help attendants apply their knowledge in real-world situations.

Quality training programs include hands-on learning opportunities where TBAs can practice skills under the guidance of skilled healthcare professionals such as gynecologists, pediatricians, and midwives. Regular refresher training sessions help reinforce skills and update knowledge.

Many successful programs conduct training sessions every two months, creating ongoing connections between TBAs and the formal healthcare system. This continuous engagement ensures that traditional practitioners remain updated on best practices and feel supported in their role.

Linking TBAs to the formal healthcare system 🔗

One of the most critical aspects of TBA training is establishing strong connections between traditional practitioners and the formal healthcare system. This integration ensures that women can access higher levels of care when needed.

Referral systems 🔗

Training programs teach TBAs when and how to refer patients to healthcare facilities. An adequate referral system allows TBAs to use their close ties with the community to connect pregnant women with skilled birth attendants. Training that advocates collaboration and regular involvement in clinic duties increases the number of referrals and improves communication between community providers and facility-based healthcare workers.

New roles for TBAs 🔗

Modern approaches recognize that TBAs can play valuable roles beyond conducting deliveries. These include encouraging women to attend antenatal and postnatal care appointments, providing companionship during childbirth, participating in community-level health education, and serving as links in referral chains for skilled care.

Community support for training initiatives 🔗

The success of TBA training programs depends significantly on community engagement and support. Programs that involve community members in planning and implementation tend to be more effective and sustainable.

Building trust and acceptance 🔗

Communities must understand the benefits of training programs for pregnant women and newborns. When families see improved outcomes from trained TBAs, they become advocates for safe practices and institutional referrals when necessary.

Addressing cultural factors 🔗

Effective training programs respect traditional knowledge while introducing evidence-based practices. Facilitating knowledge sharing between TBAs and skilled birth attendants creates collaborative relationships that benefit both providers and the communities they serve. Training that lacks cultural sensitivity or fails to consider local realities is less likely to succeed.

Providing resources and incentives 🔗

Sustainable programs often include provision of supplies such as safe delivery kits and, in some cases, compensation or incentives for TBAs. Formalizing their roles and responsibilities helps integrate them into the broader healthcare system and ensures continued participation in training and referral networks.

The evolving role of TBAs in maternal health 🔗

The World Health Organization’s 2012 guidelines recognize that trained TBAs can play an important role in improving maternal and newborn health, particularly in administering certain interventions like misoprostol for preventing postpartum hemorrhage.

While the global health community continues to promote skilled attendance at every birth as the ideal standard, the reality in many underserved areas is that TBAs will continue to provide maternal care for years to come. Evidence suggests that TBAs are acceptable to populations, accessible in needed numbers, capable of absorbing training, and cost-effective-making them valuable resources for improving maternal and infant health in developing regions.

The goal is not to replace traditional practitioners but to enhance their skills and integrate them into healthcare systems in ways that improve outcomes for mothers and babies while respecting community traditions and preferences.

What do you think? How can healthcare systems better support traditional birth attendants in your community while ensuring safe delivery practices? What role do you believe cultural traditions should play in modern maternal health programs?

References

1. https://en.wikipedia.org/wiki/Traditional_birth_attendant
2. https://pubmed.ncbi.nlm.nih.gov/2866113/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC4267086/
4. https://www.ncbi.nlm.nih.gov/books/NBK361898/
5. https://www.jssbilaspur.org/dai-training/
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC6703286/
7. https://www.ncbi.nlm.nih.gov/books/NBK584050/